Form Dr-700012 - Application For Certification Of Communications Services Database

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DR-700012
Application for Certification of
R. 05/11
Communications Services Database
Rule 12A-19.100
Florida Administrative Code
Please Read Instructions First
Check one:
Check one:
❑ Application for certification of database
❑ Provider of communications services
❑ Application for recertification of database
❑ Vendor (See Special Instructions for Vendors on page 3.)
❑ Both provider and vendor
(Check if the database is used both
internally and offered to other providers as part of a service.)
Section A - Business Information
Providers must enter this number. It is on the Certificate of Registration,
Form DR-700014.
Business Partner Number
Enter your Federal Employer Identification Number (FEIN).
Federal Employer
Identification Number
Check one:
❑ Corporation
❑ Sole proprietorship
❑ Partnership
❑ Other (please specify) __________________________________
Business name ______________________________________________________________________________________________________
Business location address ____________________________________________________________________________________________
City ________________________________________________________ State ___________________________ ZIP ___________________
Business mailing address _____________________________________________________________________________________________
City ________________________________________________________ State ___________________________ ZIP ___________________
Section B – Contact Person
Applicant must designate a contact person responsible for providing access to all records, facilities, and processes that the Department determines are reasonably
necessary to review and make a determination regarding this application.
Name of contact person (please print) ___________________________________ Telephone number _____________________________
Address ____________________________________________________________________________________________________________
Fax number __________________________________________________________ E-Mail address ________________________________
Section C – Authorized Signature
Signature of person authorized to request certification on behalf of applicant.
Signature ____________________________________________________________ Date _________________________________________
Name (please print) ___________________________________________________ Title __________________________________________
Address ____________________________________________________________________________________________________________
Section D – Database Method of Submission (
Check one)
❑ Data file will be submitted electronically (See Submitting Your File in instructions.)
❑ Data file is included with this application.
DOR Use Only
Mail application to:
Received by LGU ________________________________________
CST Database Certification
Local Government Unit
Date ____________________________________________________
Florida Department of Revenue
Application complete _____________________________________
PO Box 6530
Tallahassee FL 32314-6530
Date ____________________________________________________
For assistance completing your Application for Certification or submitting your data file, please contact the Local Government Unit at
850-717-6630.

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